Study protocol: Examining sexual and reproductive health literacy in Mexican American young women using a positive deviance approach.

Health literacy is generally low in marginalized groups, leading to delays in accessing care, poor health outcomes, and health disparities. Yet, some individuals in these groups demonstrate higher health literacy and better health outcomes. These exceptional cases exemplify 'positive deviance' because they have found ways to be successful where others have not. Identifying the methods, practices, and resources that these individuals have used to gain health literacy and healthcare access may have generalized application to improve health literacy, access to care, and health outcomes. Using the Integrated Model of Health Literacy, the main objectives of this study are to (1) identify facilitators, barriers, and strategies to gain sexual and reproductive health literacy and healthcare access and (2) to explore each of the core domains of health literacy as they relate to successful access of sexual and reproductive healthcare services among individuals identified as positive deviants. For the purposes of this mixed methods community engaged study, positive deviants are defined as Mexican American young women aged 18-29 years old living in Rural Western New York who have accessed sexual and reproductive healthcare within the past year. A community advisory committee will be formed to provide community-engaged guidance and support for the recruitment of participants. Positive deviants will participate in a survey and semi-structured interview. Data collection and analysis will be simultaneous and iterative. Results will provide evidence of positive deviant methods, practices, and strategies to gain health literacy and access to sexual and reproductive healthcare. Findings may reveal characteristics and patterns in the relationship of health literacy and healthcare access that can inform interventions to improve health literacy and make healthcare more accessible for this demographic group and context.

Procurement of patient medical records from multiple health care facilities for public health research: feasibility, challenges, and lessons learned.

Objectives: Studies that combine medical record and primary data are typically conducted in a small number of health care facilities (HCFs) covering a limited catchment area; however, depending on the study objectives, validity may be improved by recruiting a more expansive sample of patients receiving care across multiple HCFs. We evaluate the feasibility of a novel protocol to obtain patient medical records from multiple HCFs using a broad representative sampling frame. Materials and Methods: In a prospective cohort study on HIV pre-exposure prophylaxis utilization, primary data were collected from a representative sample of community-dwelling participants; voluntary authorization was obtained to access participants' medical records from the HCF at which they were receiving care. Medical record procurement procedures were documented for later analysis. Results: The cohort consisted of 460 participants receiving care from 122 HCFs; 81 participants were lost to follow-up resulting in 379 requests for medical records submitted to HCFs, and a total of 343 medical records were obtained (91% response rate). Less than 20% of the medical records received were in electronic form. On average, the cost of medical record acquisition was $120 USD per medical record. Conclusions: Obtaining medical record data on research participants receiving care across multiple HCFs was feasible, but time-consuming and resulted in appreciable missing data. Researchers combining primary data with medical record data should select a sampling and data collection approach that optimizes study validity while weighing the potential benefits (more representative sample; inclusion of HCF-level predictors) and drawbacks (cost, missing data) of obtaining medical records from multiple HCFs.

Autonomy-supportive sexual health communication and sexual health behaviors for black and Latino MSM in the House Ball Community: Protocol for a social network analysis and exploratory structural equation model.

BACKGROUND: Black and Latino men who have sex with men (MSM) have the highest risk of HIV of any group in the U.S. Prevalence could be even higher among Black and Latino MSM belonging to the House Ball Community (HBC), an understudied community comprised primarily of Black and Latino sexual and gender minorities, with HIV prevalence from non-probability samples ranging from 4% to 38%. OBJECTIVES: Basic Psychological Needs Theory will be utilized to understand how sexual health communication (SHC) influences sexual health behaviors of HBC-MSM. The proposed study will advance this goal by describing characteristics of SHC embedded within social and sexual networks, and identifying the effects of SHC on sexual health behaviors among a sample of Black and Latino HBC-MSM. METHODS: This study entails cross-sectional quantitative survey design with internet-based data collection to test a theory-driven model of the effects of autonomy supportive communication on sexual health behaviors. Respondent-driven sampling (RDS) and internet driven sampling (ID) will be used to recruit a sample of 200 HBC-MSM. We will utilize egocentric network analysis to describe (a) the HBC-specific social and/or sexual network members who provide SHC; (b) the degree of autonomy support provided by network members, and (c) the sexual health behaviors characterizing the sample of HBC-MSM. Structural equation modeling (SEM) will be performed to test associations between autonomy supportive sexual health communication (independent variable) and sexual health behaviors (outcome), with needs satisfaction and intrinsic motivation as intervening mediators. DISCUSSION: Such knowledge is necessary to expand understanding of how SHC impacts sexual health behaviors for HBC-MSM. The study provides an critical perspective on sexual health behaviors and motivations as participants operate in HBC. Knowledge generated from this study will help improve current HIV prevention interventions, as well as inform the development of future interventions, tailored to HBC-MSM.

Psychosocial risk factors of erectile dysfunction among heterosexual men living with HIV.

ABSTRACTThe risk of erectile dysfunction (ED) is significantly higher in men living with HIV (MLWH). Despite the adverse effects of ED on quality of life for MLWH, there is a lack of research on the psychosocial factors that may influence ED, especially among heterosexual MLWH. According to a recent systematic review, findings on the psychosocial risk factors of ED in past studies have been largely conflicting or inconclusive. To bridge this gap, we analyzed psychosocial and other correlates of ED among a sample of 317 primarily Black and Latino heterosexual adult MLWH in New York City. Data collection involved quantitative surveys administered using a combination of computer-assisted personal interview and audio computer-assisted self-interview techniques. After adjusting for age and general health, the relative risk of ED among heterosexual men living with HIV was associated with higher HIV-related stigma, anxiety, depression, and negative HIV-coping; greater social support was associated with a lower risk of ED. In addition, the data were consistent with the potential effects of childhood emotional, physical, and sexual abuse and structural discrimination on the risk of ED. Overall, our research findings help provide a better understanding of the psychosocial factors associated with ED among heterosexual MLWH.

Associations between Home- and School-Based Violent Experiences and the Development of Sexual Behavior in Young Adolescent Girls in the Rural Southern Region of Malawi.

Studies show that adolescent girls who experience violence grow up with fear and develop survival mechanisms that increase their susceptibility to sexually transmitted infections including HIV. However, the relationship between violence and the development of sexual behavior in young adolescent girls is under-investigated. We examined the Malawi Schooling and Adolescent Study data to explore the associations between home- and school-based violence and sexual behaviors in 416 young adolescent girls in rural Southern Malawi. Bivariate Logistic Regression analysis was applied to determine associations. Of 353 (84.9%) girls who had sex with a male partner, 123 (34.8%) experienced home-based violence, and 53 (15%) experienced school-based violence. The odds of girls who experienced home-based violence (OR = 2.46, 95% CI = 1.21, 5.01) and those who first experienced home-based violence between 13 and 14 years (OR = 2.78, 95% CI = 1.35, 5.74) were higher among girls who had multiple sexual partners than those with a single sexual partner. With school-based violence, sexual initiation, having multiple sexual partners, and not using protection were positively associated with experiencing teasing, sexual comments, punching, and touching in private areas in transit to school and by a teacher. These results suggest that home- and school-based violence should be essential components of research and biobehavioral interventions targeting the sexual behaviors of young adolescent girls.

A network analysis of dissemination and implementation research expertise across a university: Central actors and expertise clusters.

Background: Although dissemination and implementation (D&I) science is a growing field, many health researchers with relevant D&I expertise do not self-identify as D&I researchers. The goal of this work was to analyze the distribution, clustering, and recognition of D&I expertise in an academic institution. Methods: A snowball survey was administered to investigators at University of Rochester with experience and/or interest in D&I research. The respondents were asked to identify their level of D&I expertise and to nominate others who were experienced and/or active in D&I research. We used social network analysis to examine nomination networks. Results: Sixty-eight participants provided information about their D&I expertise. Thirty-eight percent of the survey respondents self-identified as D&I researchers, 24% as conducting D&I under different labels, and 38% were familiar with D&I concepts. D&I researchers were, on average, the most central actors in the network (nominated most by other survey participants) and had the highest within-group density, indicating wide recognition by colleagues and among themselves. Researchers who applied D&I under different labels had the highest within-group reciprocity (25%), and the highest between-group reciprocity (29%) with researchers familiar with D&I. Participants significantly tended to nominate peers within their departments and within their expertise categories. Conclusions: Identifying and engaging unrecognized clusters of expertise related to D&I research may provide opportunities for mutual learning and dialog and will be critical to bridging across departmental and topic area silos and building capacity for D&I in academic settings.

HIV-serodifferent couples' perspectives and practices regarding HIV prevention strategies: A mixed methods study.

A substantial proportion of heterosexually acquired HIV infections in the U.S. occur between partners in primary relationships characterized by mixed HIV status. The U.S. Centers for Disease Control and Prevention have issued guidelines prioritizing HIV-serodifferent couples for primary HIV prevention, including treatment-as-prevention and pre-exposure prophylaxis (PrEP). Yet, very little research has been conducted to understand the perspectives and practices of HIV-serodifferent couples regarding HIV prevention strategies in the U.S. To help fill this gap, we conducted a mixed methods study with 27 mostly Black/African American and Latinx HIV-serodifferent heterosexual couples residing in New York City to explore their knowledge, attitudes, practices, and perspectives regarding combination HIV prevention, including condoms, PrEP and viral control. All couples expressed the desire to maintain viral suppression in the HIV-positive partner, which was not always achieved. There was considerable heterogeneity in the use of HIV prevention methods by couples; and several patterns emerged that were largely driven by gender and relationship dynamics. Female partners, in particular, expressed high levels of anxiety around transmission of HIV and thus desired multiple methods of protection. Healthcare providers should consider couples' psychosocial well-being, relationship quality, and other motivational factors when helping to tailor HIV preventative care for mixed-status couples.

The pragmatic, rapid, and iterative dissemination and implementation (PRIDI) cycle: adapting to the dynamic nature of public health emergencies (and beyond).

BACKGROUND: Public health emergencies-such as the 2020 COVID-19 pandemic-accelerate the need for both evidence generation and rapid dissemination and implementation (D&I) of evidence where it is most needed. In this paper, we reflect on how D&I frameworks and methods can be pragmatic (i.e., relevant to real-world context) tools for rapid and iterative planning, implementation, evaluation, and dissemination of evidence to address public health emergencies. THE PRAGMATIC, RAPID, AND ITERATIVE D&I (PRIDI) CYCLE: The PRIDI cycle is based on a "double-loop" learning process that recognizes the need for responsiveness and iterative adaptation of implementation cycle (inner loop) to the moving landscapes, presented by the outer loops of emerging goals and desired outcomes, emerging interventions and D&I strategies, evolving evidence, and emerging characteristics and needs of individuals and contexts. Stakeholders iteratively evaluate these surrounding landscapes of implementation, and reconsider implementation plans and activities. CONCLUSION: Even when the health system priority is provision of the best care to the individuals in need, and scientists are focused on development of effective diagnostic and therapeutic technologies, planning for D&I is critical. Without a flexible and adaptive process of D&I, which is responsive to emerging evidence generation cycles, and closely connected to the needs and priorities of stakeholders and target users through engagement and feedback, the interventions to mitigate public health emergencies (e.g., COVID-19 pandemic), and other emerging issues, will have limited reach and impact on populations that would most benefit. The PRIDI cycle is intended to provide a pragmatic approach to support planning for D&I throughout the evidence generation and usage processes.

The Magnetic Couples Study: protocol for a mixed methods prospective cohort study of HIV-serodifferent heterosexual couples' perspectives and use of pre-exposure prophylaxis (PrEP).

INTRODUCTION: HIV transmission within serodifferent heterosexual couples plays a key role in sustaining the global HIV pandemic. In the USA, transmission within established mixed-status couples accounts for up to half of all new HIV infections among heterosexuals. Oral HIV pre-exposure prophylaxis (PrEP) is a highly effective prevention method, although underutilised among serodifferent couples. Moreover, there is a dearth of research on US HIV-serodifferent couples' perspectives and use of PrEP, alone or in combination with other prevention methods. In this paper, we describe the study protocol for the Magnetic Couples Study, designed to fill critical knowledge gaps regarding HIV-serodifferent heterosexual couples' perspectives, experiences and utilisation of PrEP. METHODS AND ANALYSIS: The Magnetic Couples Study is a mixed methods prospective cohort study designed to describe temporal patterns and identify determinants at multiple levels (individual, couple, HCF) of PrEP outcomes along the care continuum (PrEP awareness, linkage, uptake, retention and medication adherence) among HIV-serodifferent heterosexual couples residing in New York City. The study will also examine clinical management of PrEP, side effects and changes in sexual-related and substance use-related behaviour. A prospective cohort of 230 mixed-status couples already on oral PrEP was recruited, with quarterly assessments over 18 months; in addition, a cross-sectional sample of 150 mixed-status couples not currently on PrEP was recruited. In-depth semistructured qualitative interviews were conducted with a subsample of 25 couples. Actor-partner interdependence modelling using multilevel analysis will be employed for the analysis of longitudinal dyadic data. Framework analysis will be used to analyse qualitative data. A parallel convergent design will be used for mixed methods integration. ETHICS AND DISSEMINATION: The study was approved by the University of Rochester Institutional Review Board (RSRB00052766). Study findings will be disseminated to community members and providers and to researchers and policy makers.

Autonomy-Supportive Healthcare Climate and HIV-Related Stigma Predict Linkage to HIV Care in Men Who Have Sex With Men in Ghana, West Africa.

In Ghana, the HIV prevalence among MSM is more than 10 times greater than the general population of adults, and rates of engagement in HIV medical care are low among MSM diagnosed with HIV. Using structured surveys, we investigated the impact of HIV-related stigma, same-sex behavior stigma, and gender nonconformity stigma on linkage to HIV care (LTC) in MSM (N = 225) living with HIV in Ghana. Autonomy-supportive healthcare climate (OR = 1.63, p < .01), vicarious HIV stigma (OR = 2.73, p < .01), and age (OR = 1.06, p < .004) predicted LTC. Conversely, felt normative HIV stigma negatively predicted LTC (OR = 0.65, p < .05). Finally, we identified regional disparities, with MSM from Takoradi being 4 times and 5 times more likely to be LTC compared to Kumasi and Accra, respectively. Our findings highlight the nuanced roles of stigmas in shaping the HIV care continuum among MSM living with HIV, while revealing potential gaps in current measures of HIV-related stigma.

The pragmatic, rapid, and iterative dissemination & implementation (PRIDI) cycle: Adapting to the dynamic nature of public health emergencies.

Background Public health emergencies - such as the 2020 COVID19 pandemic -accelerate the need for both evidence generation and rapid dissemination and implementation (D&I) of evidence where it is most needed. In this paper, we reflect on how D&I frameworks and methods can be pragmatic (i.e., relevant to real-world context) tools for rapid and iterative planning, implementation, evaluation, and dissemination of evidence to address public health emergencies. The Pragmatic, Rapid, and Iterative D&I (PRIDI) Cycle : The PRIDI Cycle is based on a "double-loop" learning process, reflecting the iterative and adaptive D&I, along with iterative re-consideration of goals and priorities, interventions and corresponding D&I strategies, and needs and capacities of individuals and contexts. Stakeholder engagement is essential- which itself is an evolving activity. The results of iterative evaluations should be communicated with local implementers and stakeholders through customized feedbacks. Conclusion Even when the health system priority is provision of the best care to the individuals in need, and scientists are focused on development of effective diagnostic and therapeutic technologies, planning for D&I is critical. Without a flexible and adapting process of D&I, which is responsive to emerging evidence generation cycles, and is closely connected to stakeholders and target users through engagement and feedback, the interventions to mitigate public health emergencies - such as the COVID19 pandemic - will have limited reach and impact on populations that would most benefit. The PRIDI cycle is intended to provide a pragmatic approach to support planning for D&I throughout the evidence generation process.

Preexposure prophylaxis strategies for African-American women affected by mass incarceration.

OBJECTIVE: We aimed to determine the effectiveness of various preexposure prophylaxis (PrEP) prescription strategies for African-American women impacted by mass incarceration within an urban setting. DESIGN: An agent-based model was utilized to evaluate prevention strategies in an efficient, ethical manner. By defining agents, their characteristics and relationships, we assessed population-level effects of PrEP on HIV incidence. METHODS: We tested hypothetical PrEP prescription strategies within a simulation representing the African-American population of Philadelphia, Pennsylvania. Four strategies were evaluated: PrEP for women meeting CDC indicators regarding partner characteristics, PrEP for women with a recently incarcerated male partner, PrEP for women with a recently released male partner and couples-based PrEP at time of release. Interventions occurred alongside scale-up of HAART. We evaluated reductions in HIV transmissions, the number of persons on PrEP needed to avert one HIV transmission (NNT) and the resulting proportions of people on PrEP. RESULTS: Scenarios prescribing PrEP based on criminal justice system involvement reduced HIV transmissions. The NNT ranged from 147 (couples-based scenario) to 300 (recently released scenario). The percentage of the female population covered by PrEP at any one time ranged from 0.14% (couples-based) to 10.8% (CDC-based). CDC-guideline scenarios were consistently less efficient compared to the justice-involved interventions. CONCLUSION: Expanding PrEP for African-American women and their male partners affected by incarceration should be considered in national HIV prevention goals and correctional facilities leveraged as intervention sites. Partner characteristics in the current CDC indications may be more effective and efficient if guidelines considered criminal justice involvement.

Pre-exposure Prophylaxis Use Among Men Who Have Sex with Men Experiencing Partner Violence.

Intimate partner violence (IPV) significantly increases HIV risk among MSM. Pre-exposure prophylaxis (PrEP) may provide MSM experiencing IPV an option for self-protection from HIV without requiring condom negotiation or compromising safety. This study examined relationships among various forms of IPV (physical, emotional, monitoring, controlling, and forced sex) and PrEP use among 863 MSM participating in a cross-sectional, internet-based survey. Participants reported IPV rates during the prior 6 months that were consistent with prior research (physical violence, 23.3%; emotional violence, 36.3%; monitoring, 45.1%; controlling, 25.3%; forced sex, 20.0%). Forced sex and emotional IPV were negatively associated with PrEP use in our sample; in contrast, controlling was positively associated with PrEP use. We suggest clinical IPV screenings among MSM seeking PrEP, as well as PrEP-focused interventions that explicitly address IPV.

Associations Between Relationship Power and Pre-Exposure Prophylaxis (PrEP) Use Among Men Who Have Sex With Men.

Few studies have attempted to understand relationship-level factors impacting PrEP utilization among men who have sex with men (MSM). This study examined associations between relationship power and PrEP use among 826 MSM participating in a cross-sectional, Internet-based survey. The results of our analysis indicate that decision-making dominance was positively associated with PrEP use among MSM, but the association between relationship control/overall relationship power and PrEP use was inconclusive. Furthermore, when examining specific types of decision-making dominance, equal and greater dominance compared to one's partner regarding types of sexual activity engaged in, as well as dominance more generally, were positively associated with PrEP use. However, the relationships between decision-making dominance related to condom use/sexual initiation and PrEP use were inconclusive. This study suggests that the promotion of egalitarian relationships-as well as other relationship-level determinants-should be an essential component of biobehavioral interventions targeting this population.

Syndemic factors associated with adherence to antiretroviral therapy among HIV-positive adult heterosexual men.

BACKGROUND: Suboptimal adherence to HIV antiretroviral therapy (ART) and concomitant lack of viral control can have severe consequences for health and onward transmission among persons living with HIV. Little is known about the barriers and facilitators of optimal ART adherence among heterosexual HIV-positive men. METHODS: Structural equation modeling (SEM) was performed to test a theory-derived model of ART adherence using data from a cross-sectional sample of 317 HIV-positive self-identified heterosexual men residing in New York City. We assessed a conceptual model in which mental health (depression, anxiety) and substance use dependence mediated the effects of socio-structural factors (HIV-related stigma, social support) on ART adherence, and subsequently, undetectable viral load. RESULTS: Structural equation modeling analyses indicated that men who reported higher levels of HIV-related stigma tended to experience higher levels of general anxiety, which in turn was associated with reduced probability of optimal ART adherence. Moreover, men who reported higher levels of social support tended to exhibit less dependence on illicit substance use, which in turn was associated with increased probability of optimal ART adherence. African-American men reported lower ART adherence compared to other racial/ethnic groups. CONCLUSIONS: Our findings support the hypothesis that substance use dependence and mental health problems, particularly anxiety, may be primary drivers of suboptimal ART adherence among heterosexual men, and that socio-structural factors such as HIV-related stigma and social support are potential modifiable antecedents of these drivers.

Advancing the case for nurse practitioner-based models to accelerate scale-up of HIV pre-exposure prophylaxis.

AIMS: To explore the factors that position nurse practitioners (NPs) to lead the implementation of HIV pre-exposure prophylaxis. BACKGROUND: The HIV epidemic represents a global health crisis. Reducing new HIV infections is a public health priority, especially for Black and Latino men who have sex with men (MSM). When taken as directed, co-formulated emtricitabine and tenofovir have over 95% efficacy in preventing HIV; however, substantial gaps remain between those who would benefit from pre-exposure prophylaxis (PrEP) and current PrEP prescribing practices. DESIGN: This is a position paper that draws on concurrent assessments of research literature and advanced practice nursing frameworks. METHOD: The arguments in this paper are grounded in the current literature on HIV PrEP implementation and evidence of the added value of nurse-based models in promoting health outcomes. The American Association of Colleges of Nursing's advanced nursing practice competencies were also included as a source of data for identifying and cross-referencing NP assets that align with HIV PrEP care continuum outcomes. CONCLUSIONS: There are four main evidence-based arguments that can be used to advance policy-level and practice-level changes that harness the assets of nurse practitioners in accelerating the scale-up of HIV PrEP. RELEVANCE TO CLINICAL PRACTICE: Global public health goals for HIV prevention cannot be achieved without the broader adoption of PrEP as a prevention practice among healthcare providers. NPs are the best hope for closing this gap in access for the populations that are most vulnerable to HIV infection.

Feasibility and acceptability of pre-exposure prophylaxis use among women in violent relationships.

Intimate partner violence (IPV) is associated with a high risk of HIV acquisition. Pre-exposure prophylaxis (PrEP), which does not require partner knowledge or consent, is a promising HIV risk reduction option for women experiencing IPV. Drawing on semi-structured interviews with 26 women experiencing IPV within the last six months, this study explored the feasibility and acceptability of PrEP use in this population. Slightly more than half of the women in this study expressed interest in taking PrEP when in a relationship with an abusive partner. Potential barriers to PrEP, discussed regardless of women's expressed interest in PrEP, included fear of side effects and long-term health concerns, low risk perceptions, potential partner interference, and prioritizing coping with the relationship over HIV prevention. When offering PrEP counseling, providers should inquire about IPV, as women in violent relationships may require tailored counseling to address barriers and concerns specific to their situation.

Effects of Discrimination on HIV-Related Symptoms in Heterosexual Men of Color.

HIV-related symptoms have a deleterious effect on quality of life. One determinant of HIV symptom burden among individuals of color may be discrimination. The aim of this study was to explore whether multiple lifetime discrimination events are associated with a greater number of HIV-related symptoms among heterosexual HIV-positive men of color and to examine the influence of anxiety and social support on this relationship. Data for this study were drawn from a cross-sectional survey of 307 heterosexual HIV-positive men recruited from health and social service agencies in New York City (NYC). This study indicated that the number of discrimination events experienced in one's lifetime was positively associated with the number of HIV-related symptoms experienced in the past month. Moreover, the direct effect of discrimination on HIV symptoms remained significant after anxiety was included as a mediator in the model, and there was a significant indirect effect of discrimination on HIV symptoms through anxiety. Evidence supported a potential moderated mediation effect involving social support: As social support increased, the indirect effect of discrimination on HIV symptoms through anxiety decreased. The results of this study suggest an association between discrimination and HIV-related symptom burden. Furthermore, the relationship between number of major discrimination experiences and HIV symptom burden was partially mediated by anxiety. Future research should consider how lifetime discrimination might be associated with negative health outcomes among HIV-positive individuals of color.

Willingness to Take PrEP for HIV Prevention: The Combined Effects of Race/Ethnicity and Provider Trust.

Blacks and Hispanics/Latinos are disproportionately burdened by HIV compared to non-Hispanic Whites, as evidenced by higher HIV incidence, prevalence, and deaths attributable to AIDS. Increasing the use of novel prevention techniques such as Truvada for pre-exposure prophylaxis (PrEP) could greatly help in reducing these disparities by lowering HIV incidence among these higher risk groups. Trust in providers, which may differ by race and ethnicity, may influence willingness to take PrEP. This study explores the moderating effect of race/ethnicity on trust in one's primary care provider (PCP) on PrEP willingness. This study found a significant association between PCP trust and PrEP willingness, with those with greater trust having 3.24 times the adjusted odds of being willing to try PrEP. Results regarding the effects of race and ethnicity on these outcomes, however, were inconclusive. Results indicate the importance of fostering trust between PrEP-prescribing PCPs and their patients.